Juan Piazze

Lamellar body counts compared with traditional phospholipid analysis as an assay for evaluating fetal lung maturity

Objective To compare lamellar body counts with the lecithin/sphingomyelin ratio and phosphatidylglycerol analysis in terms of assessment of risk of respiratory distress syndrome (RDS). Methods Lamellar body counts, lecithin-sphingomyelin ratios (L/Ss), and phosphatidylglycerol levels were assessed in 1611 amniotic fluid samples obtained at four clinical sites from pregnant women whose fetuses were at risk for RDS. Cases in which delivery occurred within 72 hours of sample collection (n = 833) were analyzed. Specific cutoffs for predicting the likelihood of RDS for both the lamellar body count and the L/S had been derived previously at each of the clinical sites based on receiver operating characteristic curves using unrelated samples, whereas phosphatidylglycerol was reported as either mature (present) or immature (absent). Standard clinical and radiographic criteria were used to diagnose RDS, and the diagnosis was confirmed by review of newborn records. Results One hundred (12.0%) of the 833 infants delivered within 72 hours of sample collection developed RDS. The negative predictive value of the lamellar body count (97.7%) was similar to that of the L/S (96.8%) and slightly better than that of phosphatidylglycerol analysis (94.7%) (P = .048). The lamellar body count performed as well as phospholipid analysis irrespective of gestational age or patient population. Conclusion The lamellar body count compares favorably with traditional phospholipid analysis as an assay for assessment of fetal lung maturity. Lamellar body counts are preferable because they are faster, more objective, less labor intensive, less technique dependent, and less expensive and because they can be performed with equipment available in every hospital laboratory.

Ultrasonographic patterns of fetal breathing movements in normal pregnancy

Objective: To assess through pregnancy fetal breathing movements (FBMs) patterns detected by M‐mode and Doppler velocimetry technology. Methods: In this cross‐sectional study FBMs were investigated in 1882 uncomplicated pregnancies over a 4‐year period. Abdominal and thoracic wall movements of fetuses between 14 and 40 weeks of gestation were studied by M‐Mode scan, and color Doppler velocimetry with spectral imaging analysis was used to investigate the presence of FBMs associated with nasal fluid flow velocity waveforms (NFFVWs). Results: Abdominal movements were observed in 19% of cases when gestation was less than 20 weeks and in 61% of cases when it was between 21 and 25 weeks; chest movements were significant after 21 weeks; and NFFVWs were detected at 22 weeks and increased progressively to 93% of cases at term. Conclusions: Fetal breathing movements are a complex phenomenon with a composite, progressive pattern of development during gestation.

Computerized cardiotocography in the management of intrauterine growth restriction associated with Doppler velocimetry alterations

Objective: To verify the reliability of computerized cardiotocography (cCTG) in the prediction of the oxygen metabolism status of fetuses with growth restriction and Doppler velocimetry alterations. Methods: From 24 third‐trimester cesarean section performed because of intrauterine growth restriction (IUGR) and Doppler velocimetry alterations, there were 11 cases of fetal heart rate alterations (Dawes–Redman criteria were not satisfied) and 13 cases of reactive cCTG. Fetal lung maturity was detected by amniocentesis and blood samples for umbilical blood gas analysis (UBGA) were collected before the first neonatal breath from the umbilical artery in a double‐clamped segment of the cord. Results: Umbilical cord gas analysis showed arterial cord blood pH to be 7.20 or less in 11 newborns (45.8%), 7.10 or less in 6 (25%), and 7.00 or less in 3 (12.5%). Linear regression analysis showed short‐term variation (STV) in the fetal heart rate to be significantly correlated with umbilical artery pH (r=0.49; P=0.01) and pCO2 (r=−0.50; P=0.01). There were no significant correlations between cCTG and the other UBGA parameters considered. Receiver operator curves permitted to calculate the STV values at which pathological neonatal UBGA values can be expected (pH<7.00 and pCO2>80 mmHg). A short‐term variation less than 4.5 ms was found to predict acidemia with a sensitivity of 100% and a specificity of 70% (positive predictive value, 33%; negative predictive value, 100%), and hypercarbia with a sensitivity of 100% and a specificity of 77.8% (positive predictive value, 55.6%; negative predictive value, 100%). Conclusion: In view of the results of this study, 4.5 ms for STV may be a threshold below which timing of delivery should be decided in cases of fetal growth restriction.

Prognostic value of umbilical-middle cerebral artery pulsatility index ratio in fetuses with growth restriction

Objective: To study the utility of Doppler velocimetry and computerized cardiotocography in the management of intrauterine growth restriction and prediction of neonatal outcome. Patients and methods: Seventy‐two pregnant women with fetuses showing growth restriction and delivered within 48 h of their last Doppler velocimetry evaluation. The last computerized cardiotocographic trace from these fetuses was used for statistical analysis, and the last trace from the healthy fetuses of 93 consecutive women undergoing cesarean section was used as control. Umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI), UA PI / MCA PI ratio, and uterine artery resistance index (Ut RI) were assessed. Results: Among women with growth‐restricted fetuses, all parameters were significantly higher in those who had hypertension; and in those who had diabetes, only the UA PI / MCA ratio was significantly higher. Umbilical artery PI values and the UA PI / MCA ratio were higher in those who had a nonreassuring result to computerized nonstress test immediately before delivery. A multiple logistic analysis showed that the UA PI / MCA ratio was the only Doppler velocimetry parameter predicting cardiotocographic nonreactivity; furthermore, the predictivity of extended newborn hospitalization (longer than 15 days) was verified, with a sensitivity of 56% and a specificity of 92% when the ratio was higher than 1.26. Conclusion: The MCA PI of fetuses with growth restriction should be assessed. The UA PI / MCA ratio is predictive of a nonreactive computerized cardiotocography trace and of prolonged neonatal hospitalization.

Mean platelet volume: Association with adverse neonatal outcome

The aim of the study was to investigate on a possible association between maternal mean platelet volume (MPV) and oxygen-metabolic changes in pregnancies affected by altered maternal-fetal Doppler velocimetry. We considered the altered maternal-fetal Doppler velocimetry group (n = 57) pregnant women admitted to our Institution for a pregnancy complication associated to the event Pre-eclampsia (PE) and intrauterine growth retardation (IUGR), with altered Doppler velocimetry in the umbilical artery ( UA) (high pulsatility index, absence or reverse end diastolic flow (ARED), blood flow cephalisation) and/or bilateral increased resistance in uterine arteries. Out of these cases, 25 pregnancies were complicated by PE and 32 pregnancies were complicated by IUGR. We included 145 normotensive third trimester pregnant women as a normal maternal-fetal Doppler velocimetry control group. From all women, 20 ml of whole venous blood was obtained from the antecubital vein soon after Doppler velocimetry evaluation. MPV was significantly higher in women with abnormal Doppler velocimetry compared to those with normal Doppler velocimetry (8.0 fl [7.0–8.7] vs. 9.1 fl [8.0–10.6], <0.001. Values are median [interquartiles]). We performed a ROC curve in order to find an MPV cut-off able to predict an uneventful event in Doppler velocimetry compromised fetuses (neonatal O2 support > 48 hrs or intubation and/or pH < 7.2 at umbilical blood gas analysis (UBGA)). An MPV ≥ 10 fl was significantly related to the former diagnostic endpoints compared to that of non-compromised fetuses (sensitivity: 45%, specificity: 89.7%, 95 CI: 18.8–66, p < 0.01). Our study suggests that pregnancies affected by Doppler velocimetry alterations, an MPV value ≥ 10 fl may be associated with severe oxygen support and/or low UA ph at birth.

Fetal lung maturity in pregnancies complicated by insulin-dependent and gestational diabetes: a matched cohort study

OBJECTIVE To study fetal lung maturity (FLM) as determined by amniotic fluid (AF) tests in diabetic pregnancies (DP) under euglycemic metabolic control, in comparison with matched controls (C). PATIENTS AND METHODS From 514 consecutive pregnancies where amniocentesis was performed for FLM assessment, we selected 45 glycemic controlled DP. Nineteen DP were Type I (IDDM) and 26 pregnancies were diagnosed Type III (GDM). Cases were matched to C by therapy with corticosteroids, gestational age at amniocentesis, pregnancy complications other than diabetes and gender. FLM was determined by the shake test and lamellar bodies (LB) count, lecithin/sphingomyelin (L/S) ratio (planimetric and stechiometric) and phosphatidylglycerol presence (PG). DP were further sub-divided according to gestational age period at amniocentesis, type of diabetes, associated therapy and fetal malformations. RESULTS RDS (n=2) and neonatal wet lung (n=5) were diagnosed in neonates from diabetic mothers. We found no statistical difference when comparing FLM indices between DP and C groups: shake test 3.1:1+/-1.2 vs. 2.7:1+/-1.2, P<0.40; planimetric L/S 3.4+/-1.4 vs. 3.1+/-2.0, P<0.27; stechiometric L/S 8.2+/-7.4 vs. 7.1+/-6.1, P<0.54; percentage of PG positivity 57% vs. 46%, P<0.13; lamellar bodies count (X10(3)/microl) 42.8+/-36.9 vs. 41.5+/-30.4, P<0.72. No differences were found between DP and controls for subgroups according to gestational age, type of Diabetes (IDDM or GDM), congenital lesions and associated therapy. CONCLUSIONS In euglycemic, metabolically controlled diabetic patients FLM is not delayed, however an increased risk for neonatal wet lung should be considered.

Mean platelet and red blood cell volume measurements to estimate the severity of hypertension in pregnancy

Sir, We investigated the alterations in platelets, granulocytes, and RBC characteristics in cases affected by hypertension in pregnancy, in order to evaluate the severity of the disease. Pregnancy induced hypertension is defined as blood pressure )140/90 mmHg for the first time during pregnancy, without proteinuria. Preeclampsia (PE) is a complication of pregnancy affecting about 10% of primiparous women during the second half of pregnancy, is characterized by increased blood pressure and proteinuria, and is often associated with intrauterine growth restriction (IUGR). Changes in platelets and red blood cells (RBC) number and volume have been reported in hypertension during pregnancy w2x. Most studies have shown changes in platelet numbers, platelet survival, and mean platelet volume, which have been interpreted as evidence of increased platelet consumption w3, 4x, whereas other groups have related mean RBC volume to maternal blood pressure. The deleterious consequence of increasing blood pressure, is partially compensated by a concomitant decrease in RBC volume, thus attempting to counteract the viscous effects of a larger relative RBC mass with smaller cell size characteristics. Platelet count falls early in hypertension and precedes renal changes, proposing an active role of platelet consumption in the pathophysiology of this disorder. In the early stages of PE, platelet aggregation is increased, and in established severe disease it is decreased. This study was carried out prospectively in our Institute from January 2001 to May 2005. Sixty-one pregnant women were included in the study, with the diagnosis of

Antepartum computerized CTG and neonatal acid-base status at birth

Objective: To assess the correlation between individual computerized cardiotocography (cCTG) variables and acid‐base status at birth before the first breathing in uncomplicated term pregnancy delivered by cesarean section. Study design: A retrospective cohort study. Subjects and methods: Seventy singleton normal pregnancies delivered by elective cesarean section. The last antepartum cCTG performed within 4 h from delivery by the System 8002 (Oxford Sonicaid, UK) was correlated to umbilical blood gas analysis (UBGA) values (AVL compact 2 analyser). Considering blood gas analysis values as dependent and individual cCTG parameters as independent variables the best regression subsets followed by a backward stepwise linear regression was used. Results: There was no significant correlation of cCTG parameters with any of the values of blood gas analysis. However, when neonatal conditions, as expressed by arterial pH>7.20, Becf>−4.0 mmol/l and Apgar score at 5 min >7, were taken as an end‐point, they could be predicted by Acc15 and FM/hour (sensitivity: 35%, positive predictive value: 92%, cut‐off>7 and 67%, 92%, >21, respectively). Conclusion: In uncomplicated pregnancies, the prospect of a vigorous newborn seems particularly associated with the presence of Acc>15 and FM/hour>21.

Efficacy of three different antithrombotic regimens on pregnancy outcome in pregnant women affected by recurrent pregnancy loss

Introduction: Recurrent pregnancy loss (RPL) is a common health problem affecting 1–5% of women at reproductive age. Aim of the study: Evaluation of three different antithrombotic treatments in women with antecedent of RPL, comparing the results in negative and positive to thrombophilic screening pregnant women. Materials and methods: We recruited 361 women with an antecedent of two or more pregnancy losses. From this group, 167 women became pregnant and considered for the study. The evaluated pregnant women were divided as negative/positive to thrombofilic screening: (a) 80 (48%) with negative thrombophilic screening, (b) 87 (52%) positive to thrombophilic screening. Pregnant women included in the study and considered negative or positive for thrombophilic screening, were randomized into three different therapy groups: (a) group 1: Acetil salicylic acid (ASA) 100 mg daily until third month of pregnancy, (b) group 2: low molecular-weight heparin (LMWH) – enoxaparine 40 mg daily until third month of pregnancy, (c) group 3: ASA 100 mg plus LMWH 40 mg daily until third month of pregnancy. Results: In 80 negative to thrombophilic screening pregnant women, the comparison of efficacy of the three treatments, shows that all three treatment regimens were significantly effective comparing live births against fetal losses. In 87 positive to thrombophilic screening pregnant women, the comparison of efficacy for the three regimens, shows that the therapy with LMWH or LMWH plus ASA are significantly protective against fetal losses with respect to ASA, which showed a high number of fetal losses (11 live births, 18 fetal losses). Comment: We suggest that thromboprophylaxis is indicated in women with RPL independently from positiveness to thrombophilic markers.

Structural-tridimensional study of yolk sac in pregnancies complicated by diabetes

Abstract Objectives: To assess by two- and three-dimensional ultrasound the diameter and volume of the yolk sac in pregnant women affected by type 1 diabetes during the first trimester of pregnancy. Methods: 18 women affected by insulin-dependent diabetes mellitus (IDDM) and 52 normoglycemic pregnant women (controls) were enrolled in this study. The women were evaluated once a week (5–12 weeks of pregnancy). Ultrasound examination in all pregnant women was initially performed in a bidimensional fashion with a transvaginal 6.5-MHz probe and subsequently using a three-dimensional technique. Results: In the pregnant diabetic women the diameter of the yolk sac was significantly higher than that of controls in the first weeks of pregnancy, reaching a maximum diameter at 9 weeks, and decreasing thereafter, earlier than controls. The volume of the yolk sac increased in both groups from 5 weeks of pregnancy and reached maximum values at 10 weeks in both groups. The volumetric increase and decrease after reaching highest values were greater in IDDM patients. Conclusion: The clinical and diagnostic implications of the results of this study are still to be defined. Such a diagnostic technique may prove to be an additional element in monitoring diabetic women during early pregnancy.